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Biomedical subjects

K Kroenke

Publications and source records attributed to K Kroenke.

At least 19 recordsLinked to original sources
PubMed1999

Validity and utility of patient-reported health measures on hospital admission.

Patient perceptions of their health are often inadequately captured and explored on hospital admission where physiologic and other objective measures are the focus of attention. Therefore, we conducted a prospective study to develop and validate measures of several domains of patient-reported health status at the time of admission to a general medicine inpatient service, and to determine the value of these new measures in predicting length of stay (LOS). Within 2 hours of the time that a decision to admit a patient was made, research assistants delivered a structured interview that captured patients' current symptoms, functional status, mood, and perceived health. Interviews were conducted between 8 a.m. and 11 p.m., 5 days per week from July 1996 through June 1997. During this time, there were 3621 unique patients admitted to the medicine service; 2672 (74%) of these patients were eligible for an interview. Eighty-eight percent of the 2672 eligible patients were interviewed. In addition to the patient-reported measures captured through the structured interview, the acute physiology score (APS) of the APACHE II was calculated for all subjects. The internal consistency (i.e., Cronbach's alpha) of the scales was 0.76 or greater and concurrent validity (i.e., correlation) of the patient-reported measures with the APS was 0.01 to 0.13. Overall perceived health was correlated 0.20 to 0.45 with symptoms and functional status, and was correlated 0.07 with the APS. The patient-reported measures performed comparably to the APS in predicting LOS (R-square = 0.08). When the patient-reported measures and the APS were included in the same model, the R-square was 0.14. These analyses suggest that patient-reported measures of health and function on admission hold validity, and that responses to as few as 15 questions can provide data that may help to explain differences in length of a hospital stay.

APACHE↗
PubMed1998

The value of screening for psychiatric disorders in rheumatology referrals.

BACKGROUND: Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown. OBJECTIVES: To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present. DESIGN: Prospective diagnostic survey. SETTING: Two hospital-based rheumatology clinics and a general medicine clinic. PARTICIPANTS: A consecutive sample of newly referred patients (n = 185) and their rheumatologists (n = 9). INTERVENTION: Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic. MAIN OUTCOME MEASURES: Psychiatric and rheumatic disorders. RESULTS: Compared with patients with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P = .008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio = 2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P = .006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62). CONCLUSIONS: Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.

Adolescent↗
PubMed1998

Clinician-educators in academic medical centers: a two-part challenge.

As academic medical centers increasingly deliver care in primary care settings, a new category of faculty-clinician-educators-has emerged. Although the shift of education and patient care to outpatient settings makes the expanded role of clinician-educators necessary, it also presents challenges to clinician-educators themselves and to the institutions for which they work. This article examines these contemporary challenges (including financial constraints, undefined processes of promotion, and limited opportunities for professional development) and suggests strategies for meeting them. The number of clinician-educators joining the ranks of medical school faculties will probably continue to increase. As clinician-educators seek to provide the highest-quality education and patient care in the new medical marketplace, their success will be critical to the viability of the academic centers of the future.

Academic Medical Centers↗
PubMed1998

The value of screening for psychiatric disorders prior to upper endoscopy.

Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.

Adult↗
PubMed1998

A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts.

OBJECTIVE: To compare physicians' and their patients' attitudes toward pharmaceutical gifts. DESIGN: Survey of physicians and their patients. SETTING: Two tertiary-care medical centers, one military and one civilian. PARTICIPANTS: Two hundred sixty-eight of 392 consecutively surveyed physicians, 100 of 103 randomly selected patients at the military center, and 96 patients in a convenience sample at the civilian center completed the survey. MEASUREMENTS: Participants rated 10 pharmaceutical gifts on whether they were appropriate for physicians to accept and whether they were likely to influence prescribing. Patients found gifts less appropriate and more influential than did their physicians. About half of the patients were aware of such gifts; of those unaware, 24% responded that this knowledge altered their perception of the medical profession. Asked whether they thought their own physician accepted gifts, 27% said yes, 20% no, and 53% were unsure. For patients, feeling that gifts were inappropriate was best predicted by a belief that gifts might influence prescribing, while for physicians, the best predictor was knowledge of guidelines. CONCLUSIONS: Patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians.

Attitude of Health Personnel↗
PubMed1998

Outcome in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up.

BACKGROUND: Although physical complaints account for over half of all ambulatory visits, surprisingly little is known about their natural history and factors affecting prognosis. OBJECTIVES: Our aims were to determine the outcome in general medical patients presenting with physical complaints and to delineate which factors impact upon recovery rates. METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed in order to determine symptom characteristics, the presence of depressive or anxiety disorders, and expectations regarding the visit. Outcomes were assessed immediately post-visit and at 2 weeks and 3 months. The primary outcome was symptomatic improvement, and secondary outcomes included functional status, unmet expectations, satisfaction with care and visit costs. RESULTS: The majority (70%) of patients improved by 2 weeks follow-up and, of those who had not, 60% got better within 3 months. Moreover, relapse in patients initially better at 2 weeks was uncommon (6%) in the ensuing several months. While symptoms of recent onset had the highest improvement rates, half of those patients whose symptom had been present a year or longer also improved within 2 weeks. Improvement rates varied somewhat by symptom type, but no specific symptom had an improvement rate of less than 50%. Patients who had not improved at 2 weeks were more likely to report continuing serious illness worry, unmet expectations, functional impairment and dissatisfaction, even 3 months after the initial visit. CONCLUSION: Most general medical patients with physical complaints improve within 2 weeks of their initial clinic visit. Further attention may best be focused on the minority of patients who fail to improve and experience continuing concerns and impairment.

District of Columbia↗
PubMed1998

Multiple organ toxicity from addition of erythromycin to long-term lovastatin therapy.

A patient who had taken lovastatin for 7 years received erythromycin before dental procedures. Multiple organ toxicity developed, manifested as rhabdomyolysis, acute renal failure, pancreatitis, ileus, livedo reticularis, and elevated aminotransferase values, without liver injury. No previous reports have identified multiple organ injury of this magnitude. A computer literature search identified only three other reported instances of erythromycin and lovastatin interaction. Manifestations in these previous cases consisted of rhabdomyolysis in all three, as well as elevated aminotransferase values and acute renal failure in two cases. In all the cases, the clinical presentation of organ toxicity occurred after the cessation of erythromycin therapy between day 1 and day 5. Advanced age and chronic renal insufficiency were identified as potential risk factors for drug interaction. Health care professionals should be aware of the potential interaction between these two commonly prescribed drugs, which can mimic sepsis.

Acute Kidney Injury↗
PubMed1998

Chronic medications in the perioperative period.

BACKGROUND: While most chronic medications can be safely continued in the perioperative period, decisions regarding certain medications remain controversial. METHODS: We mailed a questionnaire to all 150 anesthesiology program directors in the United States, with 113 (75%) responding. Opinions regarding preoperative discontinuance or modification of selected medications were assessed. RESULTS: Antiplatelet agents are typically discontinued preoperatively, although the number of days varies widely. Few respondents discontinue tricyclic antidepressants, oral contraceptives, diuretics, or oral hypoglycemic agents. For a patient on insulin, the most popular regimen is half the patient's usual dose of neutral protamine Hagedorn insulin (50%) or no preoperative insulin (37%), whereas an insulin infusion for tight control was rarely advised. Respondents varied widely in their approach to steroid coverage, their cancellation of elective operations in patients with inadvertent aspirin ingestion, and the length of time before surgery they would discontinue warfarin. In patients with chronic atrial fibrillation, 72% of respondents favored use of a heparin window preoperatively. CONCLUSIONS: Practice variations regarding insulin regimens, steroid coverage, aspirin, and anticoagulants reflect a lack of firm evidence favoring one approach.

Adult↗
PubMed1998

Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures.

Toxic or environmental exposures have been suggested as a possible cause of symptoms reported by Gulf War veterans. To further explore this hypothesis, we analyzed findings in 18,495 military personnel evaluated in the Department of Defense Comprehensive Clinical Evaluation Program. The program was established in 1994 to evaluate Persian Gulf veterans eligible for Department of Defense medical care who had health concerns after service in the Persian Gulf during Operation Desert Shield/Desert Storm. The evaluation included a structured clinical assessment, a physician-administered symptom checklist, and a patient questionnaire addressing self-reported exposures, combat experiences, and work loss. Among 18,495 patients examined, the most common symptoms were joint pain, fatigue, headache, memory or concentration difficulties, sleep disturbances, and rash. Symptom onset was often delayed, with two-thirds of symptoms not developing until after individuals returned from the Gulf War and 40% of symptoms having a latency period exceeding one year. There was no association between individual symptoms and patient demographics, specific self-reported exposures, or types of combat experience. Increased symptom counts were associated with work loss, the number of self-reported exposures, the number of types of combat experience, and certain ICD-9 diagnostic categories, particularly psychological disorders. Prolonged latency of symptom onset and the lack of association with any self-reported exposures makes illness related to toxic exposure less likely.

Analysis of Variance↗
PubMed1997

Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome.

BACKGROUND: Specific concerns and expectations may be a key reason that people with common physical complaints seek health care for their symptoms. OBJECTIVES: To determine the frequency of symptom-related patient concerns and expectations, physician perceptions and actions, and the relationship of these factors to patient satisfaction and symptom outcome. METHODS: This was a prospective cohort study of 328 adult outpatients presenting for evaluation of a physical complaint. The setting was a general medicine clinic in a teaching hospital. Measures included previsit patient questionnaire to identify symptom-related concerns and expectations; a postvisit physician questionnaire to determine physician perceptions and actions; and a 2-week follow-up patient questionnaire to assess symptom outcome and satisfaction with care. RESULTS: Pain of some type accounted for 55% of common symptoms, upper respiratory tract illnesses for 22%, and other physical complaints for 23%. Two thirds of patients were worried their symptom might represent a serious illness, 62% reported impairment in their usual activities, and 78%, 46%, and 41% hoped the physician would prescribe a medication, order a test, or provide a referral. Physicians often perceived symptoms as less serious or disabling and frequently did not order anticipated tests or referrals. While symptoms improved 78% of the time at 2-week follow-up, only 56% of patients were fully satisfied. Residual concerns and expectations were the strongest correlates of patient satisfaction. CONCLUSIONS: Improved recognition of symptom-related concerns and expectations might improve satisfaction with care in patients presenting with common physical complaints.

Activities of Daily Living↗
PubMed1997

Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care.

BACKGROUND: For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS: Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS: Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS: Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.

Adolescent↗
PubMed1997

Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome.

PURPOSE: To identify the predictors of depressive and anxiety disorders in general medical patients presenting with physical complaints and to determine the effect of these mental disorders on patient outcome. PATIENTS AND METHODS: In this cohort study, 500 adults presenting to a general medicine clinic with a chief complaint of a physical symptom were interviewed with PRIME-MD to diagnose DSM-IV depressive and anxiety disorders. Clinical predictors were identified by logistic regression analysis. Outcomes were assessed immediately postvisit and at 2 weeks and 3 months. These included symptomatic improvement, functional status, unmet expectations, satisfaction with care, clinician-perceived patient difficulty, and health care utilization and costs. RESULTS: A depressive or anxiety disorder was present in 146 (29%) of the patients. Independent predictors of a mental disorder included recent stress, multiple physical symptoms (ie, 6 or more), higher patient ratings of symptom severity, lower patient ratings of their overall health, physician perception of the encounter as difficult, and patient age less than 50. Patients with depressive or anxiety disorders were more likely to have unmet expectations postvisit (20% versus 8%, P < 0.001), be considered difficult (26% versus 11%, P < 0.0001), and report persistent psychiatric symptoms and ongoing stress even 3 months following the initial visit. Psychiatric status was not associated with symptomatic improvement, health care utilization, or costs. CONCLUSION: Simple clinical clues in patients with physical complaints identify a subgroup who may warrant further evaluation for a depressive or anxiety disorder. Such disorders are associated with unmet patient expectations and increased provider frustration.

Adult↗
PubMed1997

Increasing the use of advance directives in medical outpatients.

OBJECTIVE: We studied whether a simple educational intervention would increase patient completion of advance directives and discussions on end-of-life issues. DESIGN: Randomized, controlled trial. SETTING: Outpatient clinic of a teaching hospital. SUBJECTS: One hundred eighty-seven outpatients of a primary care internal medicine clinic. INTERVENTION: Study subjects attended a 1-hour interactive seminar and received an informational pamphlet and advance directive forms. Control subjects received by mail the pamphlet and forms only. MEASUREMENTS AND MAIN RESULTS: Completion of the advance directive was the main measurement. There were no significant differences in baseline characteristics of either group. Follow-up at 1 month revealed advance directive completion in 38% of study versus 24% of control subjects (p = .04), and discussions on advance planning in 73% of study versus 57% of control subjects (p = .02). Patients most likely to complete the documents were white, married, or attendees at the educational seminar. CONCLUSIONS: Interactive group seminars for medical outpatients increased discussions and use of written advance directives.

Adult↗